Bartee v. University Medical Center
| Decision Date | 24 January 2008 |
| Docket Number | No. 2007-SC-000094-WC.,2007-SC-000094-WC. |
| Citation | 244 S.W.3d 91 |
| Parties | Sonia BARTEE, Appellant, v. UNIVERSITY MEDICAL CENTER, Dr. Craig Roberts, Dr. Ranier Lenhart and Hon. John W, Thacker, Administrative Law Judge and Workers' Compensation Board, Appellees. |
| Court | United States State Supreme Court — District of Kentucky |
KRS 342.125 permits a final workers' compensation award to be reopened. KRS 342.125(4) gives an Administrative Law Judge (ALJ) broad authority to modify a reopened award but also provides that "[r]eopening shall not affect the previous order or award as to any sums already paid thereunder, and any change in the amount of compensation shall be ordered only from the date of filing the motion to reopen."
During the pendency of the defendant-employer's reopening to contest its liability for a surgery and after the claimant returned to work, she filed a motion to reopen to seek temporary total disability (TTD) benefits. An ALJ found that the surgery was compensable and awarded a period of TTD that began on the date of the surgery, reasoning that the employer's reopening placed the question of TTD in issue. Affirming in part and reversing in part, the Workers' Compensation Board determined that KRS 342.125(4) gave the ALJ broad authority to award. TTD because the issue was raised during the pendency of the employer's motion, but the statute did not permit TTD to be awarded before the date of the employer's motion. A divided Court of Appeals reversed. It determined that the medical dispute did not encompass the TTD issue and that KRS 342.125(4) prohibited a TTD award because the claimant filed her motion to reopen after the period of TTD expired. We affirm.
The claimant's application for benefits indicated that she injured her knee on May 9, 1996, within the scope and course of her work for the defendant-employer. She testified subsequently that her work as a file clerk required her to stand and pull files and that she felt her knee pop as she was reaching for a file. Records from Occupational Physicians Services indicated that she sought treatment that day and was permitted to return to work described as "sit down duty." She underwent surgery on June 24, 1996, and returned to light duty work in August 1996.
On July 16, 1997, an ALJ approved an agreement to settle the claim. The agreement described the injury as a tear of the lateral meniscus of the left knee and the arousal of a pre-existing condition. It listed the employer and the Special Fund as being defendants and stated that they bore equal liability for income benefits based on a 16.4% permanent partial occupational disability. The agreement also provided that related medical expenses were "to be paid pursuant to statute."
The claimant's symptoms failed to abate, and controversies arose over her medical treatment. A December 12, 2000, letter from the employer's insurance carrier to the claimant's treating physician stated that that physical therapy had been authorized and that the claimant "was 100% wrong when she told you we had denied physical therapy." The statement was consistent with the relevant pre-certification form. A subsequent medical dispute was settled on May 16, 2002, with the parties agreeing that the Pain Control Network would receive a lump sum of $1,500 but that the provider's future treatment would be subject to utilization review.
The present controversy arose after a left knee MRI performed in March 2004 revealed a tear in the anterior lateral meniscus. The claimant's treating physician recommended surgery, and the employer's carrier submitted the request and the claimant's medical records to Dr. Wolens for utilization review. He noted that the MRI finding did not correlate with her symptoms or with the fact that the original tear was posterior rather than anterior. Thus, the carrier refused to pre-certify the. surgery.
The claimant underwent the procedure on April 21, 2004. At her request, the carrier reconsidered its denial and submitted the claim to Dr. Loeb for another utilization review. After he concluded that the surgery was unrelated to the work injury, the carrier refused payment. On June 8, 2004, the employer filed a motion to reopen in order to contest its liability and a motion to join the medical providers. The claimant joined in the motions, and they were granted to the extent that the Chief ALJ reassigned the matter for further adjudication. The claimant testified in the medical dispute that she returned to work on June 21, 2004.
On September 10, 2004, the claimant filed a motion to reopen. It alleged that the employer refused to authorize additional medical treatment and/or refused to pay for treatment and also alleged that her temporary or permanent disability had increased since she settled the initial claim. The ALJ sustained the motion but determined on reconsideration that the period of limitations found in KRS 342.125(3) and (8) barred reopening for increased permanent disability benefits. Although the parties' motions were consolidated, the sole issue listed on the May 3, 2005, benefit review conference memorandum was "medical fee dispute/compensability of surgery." The claimant asserted in her brief not only that the surgery was compensable but also that she was entitled to TTD benefits from the date of the surgery until her return to work.
The ALJ held that the employer was liable for the surgery and related medical treatment. Based on the claimant's petition for reconsideration, the ALJ amended the decision to award TTD benefits from April 24, 2004, through June 21, 2004. In denying the employer's petition for reconsideration of the amended order, the ALJ reasoned that because the surgery resulted TTD, the issue of TTD arose from the employer's reopening to contest the surgery. The ALJ also found that the principles of waiver and estoppel precluded the employer from objecting to TTD because the issue arose in the natural course of events from the issue regarding the compensability of surgery.
The Board affirmed in part but adopted a different rationale. It acknowledged that the claimant filed her motion to reopen after she returned to work and that KRS 342.125(4) normally would have precluded a TTD award. It reasoned, however, that because she raised the TTD issue during the pendency of the employer's reopening, the broad authority that KRS 342.125(4) gave the ALJ over the reopened claim permitted the ALJ to award...
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